Business Information
Business Information
| Business Name |
J. H. Romine Agency Farmers insurance
|
| Business Street Address (Including Unit or Suite, if applicable) |
---
|
| Business Phone |
+18158621234
|
| Business Fax |
---
|
| Email Address |
---
|
| Would you like to sign up for the Village E-Blast for current events and information? |
---
|
| Website Address |
---
|
Business Owner Information
| Business Owner(s) Name |
---
|
| Business Owner(s) Home Address |
---
|
| Business Owner(s) Phone Number (Home or Cellphone) |
---
|
| Building's Landlord (if Different from Owner) |
---
|
| Landlord Address (Incl. City, State, Zip Code) |
---
|
Is This A New Business?
| Is This A New Business? |
No, my business was registered under the same name prior to May 1st of this year.
|
Other Important Information
| Illinois Sales and Use Tax and/or Retailers Occupation Tax |
---
|
| Operating Days |
Monday, Tuesday, Wednesday, Thursday, Friday
|
| Operating Hours |
8am-5pm
|
| Number of Shifts |
1
|
| Number of Employees |
4
|
| Nature of Business |
Insurance
|
Fueling Stations
| Does your business have fueling stations on site? |
No
|
Hoses
Police Required Information
| Burglar Alarm |
No
|
| Fire Alarm |
No
|
| Hazardous Materials |
No
|
Emergency Contacts: Please provide 3 names/phone numbers of key holders who are available 24 hours in case of an emergency.
| 1) Name |
Lacey Thomas
|
| 1) Phone Number |
+14057888224
|
| 1) Alternate Phone Number |
+18155931279
|
| 2) Name |
Jack Romine
|
| 2) Phone Number |
+12624967755
|
| 3) Name |
Lori Romine
|
| 3) Phone Number |
+18476502604
|
Initial Review
Late Fees
| Was this submitted after May 22? |
No
|
Prorated Fees
| Was this submitted between August 1 - October 31? |
No
|
| Was this submitted between November 1 - January 31? |
No
|
| Was this submitted After February 1? |
No
|
Assign Certificate Number
Certification Number
